Nokea
A client tells the nurse that she is allergic to eggs, dogs, rabbits, and chicken feathers. Which order should the nurse question?
- A. TB skin test
- B. Rubella vaccine
- C. ELISA test
- D. Chest x-ray
Correct Answer: B
Rationale: The rubella vaccine is contraindicated in clients with egg allergies, as it may be grown in egg-based cultures.
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The nurse is assessing a trauma client in the emergency room when she notes a penetrating abdominal wound with exposed viscera. The nurse should:
- A. Apply a clean dressing to protect the wound
- B. Cover the exposed viscera with a sterile saline gauze
- C. Gently replace the abdominal contents
- D. Cover the area with a petroleum gauze
Correct Answer: B
Rationale: Covering exposed viscera with sterile saline gauze keeps the tissue moist and prevents infection until surgical intervention, as replacing contents or using non-sterile dressings risks contamination.
A 22-year-old pregnant client is diagnosed with autoimmune hemolytic anemia. The nurse anticipates immediate treatment with
- A. IgA.
- B. IgG.
- C. IgE.
- D. IgD.
- E. None
Correct Answer: E
Rationale: Autoimmune hemolytic anemia in pregnancy is typically treated with corticosteroids or IVIG (containing IgG), but IgG alone isn’t administered. None of the options are correct.
The nurse is performing discharge teaching to the parents of a 7-year-old who has been diagnosed with asthma. Which sports activity would be most appropriate for this client?
- A. Baseball
- B. Swimming
- C. Football
- D. Track
Correct Answer: B
Rationale: Swimming is ideal for asthma clients as it promotes controlled breathing in a warm, humid environment, reducing the risk of exercise-induced bronchospasm.
The nurse is talking in the lounge with other nurses about grief and loss. The nurse understands which to be true regarding grief and loss? Select all that apply.
- A. The process of grief is detrimental to physical and emotional health.
- B. Age, gender, and culture are a few factors that influence the grieving process.
- C. The nurse must explore his own feelings about death before he may effectively help others.
- D. The nurse should discourage expression of grief and loss because it may upset other clients nearby.
- E. The nurse can help the family develop ways to relieve loneliness and depression following the death of a loved one.
Correct Answer: B, C, E
Rationale: Age, gender, and culture influence grief; nurses must process their own feelings to help others, and supporting families post-loss is key. Grief is not inherently detrimental, and expression should be encouraged.
The nurse is caring for a child in a plaster-of-Paris hip spica cast. To facilitate drying, the nurse should:
- A. Use a small hand-held hair dryer set on medium heat
- B. Place a small heater near the child's bed
- C. Turn the child at least every 2 hours
- D. Allow one side to dry before changing positions
Correct Answer: C
Rationale: Turning the child every 2 hours ensures even drying of the cast and prevents pressure sores, promoting comfort and healing.